Social and Structural Determinants of Non Communicable Diseases (NCDs) Lessons from the evaluation of the 2007 CARICOM Heads of Government NCD Summit Declaration TTMA 22 nd Annual Conference July 24 th 2016, POS T. Alafia Samuels, Principal Investigator NCD Summit Declaration; Director, Chronic Disease Research Centre, UWI
Presentation Life expectancy and mortality disparities NCD mortality NCD risk factors Heads of Government response Evaluation of NCD Declaration Accelerating action
Regional LE in the Americas 1970-2010 International LE targets met by most countries population growth has dropped to replacement levels and life expectancy is relatively high A positive picture. But not the whole picture Prepared by Ian Hambleton, CDRC, September 2015
Country LE in the Caribbean 1970 2010 1965 70 2005 10 Monitoring variation within the Caribbean Prepared by Ian Hambleton, CDRC, September 2015
Disparities in the African diaspora diabetes cerebrovascular 77.7 73.6 71.4 64.5 76.7 73.2 71.5 67.9 heart cancer respiratory injury Prepared by Ian Hambleton, CDRC, September 2015
CVD-DIABETES Premature Mortality Women (0-64 yrs) Guadeloupe French Guiana Martinique US White-American USVI Puerto Rico Barbados Cuba Bahamas Antigua and Barbuda US African-American St.Vincent & Grenadines St.Lucia Belize Trinidad and Tobago Guadeloupe 2000: 24 per 100,000 2010: 17 per 100,000 Trinidad 2000: 134 per 100,000 2010: 84 per 100,000 0 50 100 150 Prepared by Ian Hambleton, CDRC, September 2015
CVD-DIABETES Premature Mortality Men (0-64 yrs) French Guiana Martinique Guadeloupe Barbados US White-American USVI Cuba Puerto Rico St.Vincent & Grenadines Bahamas Antigua and Barbuda St.Lucia Belize US African-American Trinidad and Tobago French Guiana 2000: 52 per 100,000 2010: 38 per 100,000 Trinidad 2000: 189 per 100,000 2010: 135 per 100,000 0 50 100 150 200 Prepared by Ian Hambleton, CDRC, September 2015
Country example: Belize Within-country disparities by gender and ethnicity injuries injuries non-communicable disease non-communicable disease communicable disease communicable disease Mestizo Garifuna Creole Mayan Mestizo Garifuna 20-24 30-34 40-44 50-54 Creole Mayan Mestizo Garifuna Creole Mayan 0 10 20 30 40 50 Mortality rate (per 10,000) 0 10 20 30 40 50 Mortality rate (per 10,000) Prepared by Ian Hambleton, CDRC, September 2015
Presentation Life expectancy and mortality disparities NCD mortality NCD risk factors Heads of Government response Evaluation of NCD Declaration Accelerating action
Source: PAHO Basic Indicators 2012
Caribbean NCD mortality NCDs: Heart attacks, stroke, diabetes, cancers are the leading causes of premature death NCD mortality in the Caribbean is the highest in the Americas, (78% of all deaths in 2010) 76% of all premature deaths (ages 30 69) are caused by NCDs (double rates in North America) Hypertension is the leading risk factor for death Diabetes prevalence is double global rates
Presentation Life expectancy and mortality disparities NCD mortality NCD risk factors Heads of Government response Evaluation of NCD Declaration Accelerating action
NCDs: Risk factors 4 Diseases, 4 Modifiable Shared Risk Factors Tobacco Use Unhealthy diets Physical Inactivity Harmful Use of Alcohol Cardiovascular Diabetes Cancer Chronic Respiratory
Evolution of the Problem
Risk excess by gender in CARICOM Women twice as likely to be obese Women 60% more likely to have diabetes Rates of tobacco use and alcohol abuse are half or even lower in women compared to men
The Man Problem 10-20% men current tobacco smokers Binge drinking among men 5+ drinks at one time in last 7 days Barbados (2012) 25% Dominica (2008) 33% Trinidad & Tobago (2012) 34% Higher rates of injuries Low health service utilization Worse control of chronic conditions Higher death rates at every age
WHO's commission on social determinants of health SDH = conditions in which people are born, grow, live, work and age, including the health system These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. http://www.who.int/social_determinants/en/
Limited data Very limited within-country data on disparities / inequalities / inequities by social determinants education, income and occupation Need to start collecting and analysing data in this way within the Caribbean.
Presentation Life expectancy and mortality disparities NCD mortality NCD risk factors Heads of Government response Evaluation of NCD Declaration Accelerating action
Sir George Alleyne speaks on health and development
In response to the NCD epidemic: September 2007 CARICOM Heads of Government issued the groundbreaking Port of Spain Declaration: Uniting to Stop the Epidemic of Chronic Non-communicable Diseases With its global resonance, the Declaration paved the way for: 2011 UN High-Level Meeting (UNHLM) on NCDs World Health Organization s international monitoring framework, with nine global targets and 25 indicators
2007 POS NCD Declaration Fully convinced that the burdens of NCDs can be reduced by comprehensive and integrated preventive and control strategies at the individual, family, community, national and regional levels and through collaborative programmes, partnerships and policies supported by governments, private sectors, NGOs and our other social, regional and international partners;
NCD Mandates and Commitments 15 Point Declaration, 27 commitments All of Government and All of Society response National, multi-sectoral NCD Commissions Risk factor reduction, including: oimplementation of Framework Convention on Tobacco Control (FCTC) omulti-sectoral food and nutrition plan opromotion of physical activity in schools and workplaces Improved quality of care for those living with NCDs Workplace Wellness Programmes Caribbean Wellness Day
Presentation Life expectancy and mortality disparities NCD mortality NCD risk factors Heads of Government response Evaluation of NCD Declaration Accelerating action
POS Evaluation Grid annually 2008-2015
Goal of the formal evaluation To evaluate, seven years on, Learn lessons that will support and accelerate its further implementation Inform the attainment of the UNHLM NCD commitments April 2014 - March 2016 research April 2016 March 2017 dissemination
Research Partners UWI Chronic Disease Research Centre Public Health Group, Cave Hill Department of Community Health and Psychiatry, Mona HEU, Centre for Health Economics, St. Augustine Institute of International Relations, St. Augustine G8 Research Group, University of Toronto Healthy Caribbean Coalition Caribbean Public Health Agency Pan American Health Organization CARICOM Canadian International Development Research Centre (funders)
Research highlights
Barriers to Success: Risk Factors Increase in foreign investment increased Westernized diets and fast food with low nutritional value Alcohol as core industry creates a barriers to political will for legislative action Reliance on food imports limits reach of legislative action including quality, and affordability of healthy foods Short project funding rather than sustained budgets hamper sustainability of actions Overreliance on physical activity promotion in terms of sports and exercise limiits broader reach Undernutrition and food poverty as parallel concerns limit impact of obesity related health education
Barriers to Success: SUMMARY International political and economic barriers to effective legislation and initiatives (e.g. food labelling and availability of healthy options) Geographical barriers: remoteness curtailing healthcare access/roll out; water scarcity for agriculture; small population with limited human resources Limited reliable surveillance and evaluation of local initiatives to provide local evidence base Political will a reflection of public awareness and acceptability, e.g. emphasis on personal responsibility Lengthy bureaucratic process of policy formulation to implementation discourages action and motivation.
Policy responses and lessons learned NCDs need to be given higher political priority The all-of-society and all-of-government response needs strengthening There are widely differing levels of implementation of Summit Declaration mandates related to: Country size Resources Burden of NCDs
Policy responses and lessons learned lowest levels of implementation: the macro determinants of diet and physical activity. highest levels of implementation: clear guidance (i.e. protocols or blue prints ) support from regional organisations (e.g. CAREC/CARPHA for risk factor surveys, WHO/FCTC for tobacco control) Local champions (e.g. Mike s Bikes)
Investing: Potential role of tobacco and alcohol taxes
Investing: Potential role of tobacco and alcohol taxes Study in three countries; Grenada, Jamaica, Trinidad and Tobago: Revenue generated from increasing taxes on tobacco and alcohol could exceed US$ 37 million 300% more than the estimated US$ 12.6 million cost of World Health Organization best buy NCD interventions
Investing in health 2014 taxation on tobacco Target taxation 75% St. Lucia 63% Suriname 56% Barbados 42% Trinidad & Tobago 30% Guyana 25% St Vincent & Gren 17%
Jamaica: Investing In Population Health National Health Fund (NHF) since 2008, partially financed by a tax on tobacco access to selected health benefits and subsidized NCD medications private and public sector projects with an emphasis on prevention.
Declaration s international impact Summit helped shape global governance of chronic diseases Paved the way for the 2011 UN High-Level Meeting (UNHLM) on NCDs Over half of the 27 CARICOM Summit commitments were reflected in the UNHLM NCD Declaration Caribbean Wellness Day/Week has been promoted by PAHO in the region of the Americas
Presentation Life expectancy and mortality disparities NCD mortality NCD risk factors Heads of Government response Evaluation of NCD Declaration Accelerating action
Accelerating action
Individual action can reduce the impact of health hazards but socio-economic factors make the job harder
Recognize that behavioural changes alone will not be enough
Levels of Intervention
Dr. Chan, DG WHO June 10, 2013 Globalization of unhealthy lifestyles is a political issue. It is a trade issue. It is an issue for Foreign Affairs Few Governments prioritize Health over Big Business
Social determinants of child obesity marketing to children childcare school environment agricultural law food systems enforcement built environment Fiscal measures
Taxes on Sugar-Sweetened Beverages 2014 Mexico 2015 Chile, Barbados, Dominica, St Vincent & Grenadines 2016 -? Belgium, Britain?? India, Phillipines, Indonesia considering CDRC doing research on SSB tax price, sales, process in Barbados, in discussions with Dominica
Partners Heads of Government Ministers of Health Permanent Secretary / Chief Medical Officer All of Government All of Society Civil society, private sector Community organisations Regional bodies International partners
Bahamas: Faith based initiatives - Seventh Day Adventists Obesity
GUYANA FITNESS WALK, led by Minister Ramsammy included the differently-abled
Port of Spain, Trinidad: Love that body, move that body
What we do in the physical and fiscal environment has more potential for impact than health education and one-to-one counselling
Changing CONSUMPTION PRICE trumps HEALTH EDUCATION Office of the Chief Medical Officer, St. Kitts & Nevis
CARICOM communiqué 37 th CARICOM Heads of Governmet Conference July 4-6, 2016 highlights renewed commitment to NCDs
As the Tenth Anniversary of the historic Port of Spain Declaration Uniting to fight the Non- Communicable Diseases (NCDs) draws near, the Heads of Government recognised the progress made in addressing the issue. They acknowledged, however, that progress was variable and agreed to adopt a more holistic approach.
In this regard, they pledged to address issues such as the banning of smoking in public places; trade related measures; banning advertisement of potentially harmful foods which specifically target children; and elevating taxes on foods high in sugar, salt and trans-fats.
Thank You